Ambulance bosses have overhauled their policies following their handling of a pregnant woman who subsequently died after she collapsed at Kensal Rise station.

An inquest into the death on 39-year-old Estherline Caulker at Inner London Coroner’s Court heard paramedics took her to Homerton Hospital in Hackney, rather than the nearest A&E departments 10 minutes away after they were called to the scene on January 16 this year.

During the 84 minute journey to east London, the 39-year-old went into cardiac arrest after medics failed to realise she was bleeding internally.

She died from a haemorrhage shortly after her daughter was delivered by emergency Caesarean.

The 14-week premature baby died two months later.

Homerton Hospital is in Hackney

Yashwant Koak, a consultant general surgeon, told coroner Mary Hassell that she would have had a 75 per cent chance of survival if she had been taken to the nearest hospitals with A&E departments both 10 minutes - St Mary’s Hospital in Paddington or The Royal Free in Hampstead.

He added by the time she arrived in Hackney her chances had plummeted to 50 per cent and by the time she went into cardiac arrest it would have been less than five per cent.

When Ms Caulker, who lived in Hackney, arrived at Homerton as a non-urgent case further time was wasted as paramedics ‘did not know the layout of the hospital’ and has to search for the maternity unit.

In addition she had to wait two hours to see a doctor.

Estherline Caulker was 39 when she died

Paramedics said they took her to the Homerton, where she was receiving ante natal care, ‘in line with her wishes’ and after they believe her condition had stabilised.

Ms Caulker, who had a Body Mass Index of 46.2 and was classed as obese, was at greater risk during her pregnancy due to her weight.

She had previously suffered four miscarriages.

Recording a narrative verdict Ms Haseel said: “There was a failure of fully effective communication between health professionals at every stage during Ms Caulker’s car… If blue light transfer to an emergency unit with maternity support had been affected from the railway station then…she would have probably survived

“By the time she reached Homerton maternity Unit, treatment was unlikely to change the outcome.”

Amanda Mansfield, consultant midwife at London Ambulance Service, told the Times: “Our ambulance crew took the patient to her preferred hospital, not realising the severity of her illness.

“We are sorry for what happened and have made a number of changes as a result. For example we have issued guidance about taking unwell pregnant women to the nearest maternity unit.

“We have also started enhanced training sessions for our crews, continue to work closely with maternity units and regularly review our procedures.”

Starlington Caulker, 66, told the Times he is considering taking legal action following the death of his youngest daughter.

He said: “I will have a meeting with my family and we consult our lawyers.

“It was the careless of all the people my daughter had contact with and a catalogue of errors that has resulted her death. If she had received proper care from scratch to finish she would still be here.”

The grandfather-of-three, who has another daughter Floretta, 42, added: “I was so looking forward to have a new grandchild and so was my mother who is 99.

An 80-year-old grandmother was called a “f***ing bitch” in a “foul outburst” by her alleged murderer months before she was strangled with a lawnmower cord in a Colindale allotment shed, the Old Bailey heard today.